Division of Cardiology, Fellowship Training Program
Baltimore VAMC Coronary Intensive Care Unit (CICU)
Goals & Objectives
Our goal is to provide the second year Cardiology Fellow with experience in the diagnosis, treatment, and
follow-up of patients with a wide range of known or suspected cardiovascular disorders. This includes the
following types of patients:
1. Patients referred for evaluation of possible cardiac-related symptoms such as chest pain, syncope,
palpitations and dyspnea or physical findings (e.g. heart murmurs).
2. Patients without documented cardiac disease but with multiple cardiac risk factors (Preventive
3. Patients with known specific cardiac diagnoses such as acute myocardial infarction, acute coronary
syndromes, congestive heart failure, chronic ischemic heart disease, cardiac valve problems and
4. Patients with known or suspected cardiac disease who require pre-operative evaluation for non-
cardiac surgical procedures.
1. Coronary Care Unit – The Fellow will make daily rounds in the Coronary Care Unit. Under the
supervision of the Attending Cardiologist, the Fellow’s duties will include screening admissions,
directing the diagnostic workup and therapy and performing or supervising the Housestaff in
bedside invasive procedures (pulmonary artery catheters, arterial lines, temporary pacemakers,
2. Other Blue Team Patients (telemetry, etc) – Although these will be primarily the responsibility of the
Housestaff and the Attending Cardiologist, the fellow will review all of these patients on a daily
basis and become involved in their care when appropriate (e.g. patients requiring cardiac
3. Consults – Under the supervision of the Attending Cardiologist, the Fellow will be responsible for
evaluating both inpatient consults and outpatient consults (that are reviewed by the Attending
Cardiologist and felt to be too urgent to be referred to Cardiology Clinic) and making appropriate
recommendations, initiating a work-up, etc.
4. Echocardiograms – The Fellow will be responsible for performing the initial reading all
echocardiograms performed at the Baltimore VA Medical Center. The echocardiograms will
subsequently be reviewed by an attending cardiologist.
5. Cardioversions – With the assistance of one of the Cardiology Physician’s Assistants, the Fellow
will help to evaluate patients scheduled for cardioversion and will direct the actual procedure.
6. Education – In conjunction with the Cardiology Attending Physician, the Fellow will actively
participate in the educational program for the Blue Team Housestaff and students. This will include
informal teaching sessions and occasional didactic lectures.
Fellows will be taught by several methods, including:
• Direct teaching by the attending during daily rounds
• Direct review of echocardiograms interpreted by the fellows by the attending
• Involvement in cardiology conferences while participating in this course
Mixes of Disease:
Fellows will be exposed to patients with a wide range of cardiac disease, including:
• Acute and chronic coronary syndromes
• Acute and decompensated heart failure
• Acute and decompensated valvular heart disease
• Pericardial disease, especially pericardial tamponade
• Simple and complex supraventricular and ventricular dysrhythmias
This will consist of patients who are both a local and tertiary referral population from other VA medical
centers. Most patients will be male with a spectrum of acute and chronic ischemic syndromes, congestive
heart failure, valvular heart disease, atrial and ventricular arrhythmias. In addition, through consultations,
fellows will see a spectrum of cardiovascular disease in patients presenting with other disorders.
Types of Encounters:
Encounters will predominantly be inpatient, and will be composed predominantly of patients in the intensive
care units. The fellow may be involved in procedures, including:
• Bedside right heart catheterization
• Bedside placement of temporary pacing catheter
• Electrical Cardioversion
• ACC/AHA guidelines for myocardial infarction (revised 1999) http://www.acc/clinical/guidelines/
• Guidelines for risk stratification after myocardial infarction. American College of Chest
Physicians. Ann Intern Med 1997;126:556-560.
• Management of patients with unstable angina and non-ST segment elevation myocardial
infarction: ACC/AHA Practice Guidelines> J Am Coll Cardiol 2000;36:970-1062.
• ACC/AHA Practice Guidelines for management of patients with valvular heart disease. J Am
Coll Cardiol 1998;32:1486-588.
• ACC/AHA Guidelines for implantations of cardiac pacemakers and antiarrhythmia devices. J
Am Coll Cardiol 1998;31:1175-209.
• Consensus staement on indications, guidelines for use, and recommendations for follow-up of
implantable cardioverter defibrillators. PACE 2001;24:262-268.
• ACC/AHA Guidelines for the management of atrial fibrillation J Am Coll Cardiol
• AHA/ACC Guidelines for preventing heart attack and death in patients with atherosclerotic
cardiovascular disease. Circulation 2001;104:1577-9.
• ACC/AHA Guidelines update for perioperative cardiovascular evaluation for noncradiav
surgery – Ecxecutive Summary. J Am Coll Cardiol 2002;39:543-553
• ACC/AHA Guidelines for coronary artery bypass surgery. J Am Coll Cardiol 1999;34:1262-347.
Level of Supervision:
Fellows will be directly supervised during rounds in the intensive care unit by the attending physician. The
attending will be immediately available for consultation regarding these patients after rounds. Procedures
performed by the fellows will be done so under the direct supervision of the attending physician.
The fellow will be receive direct oral and written feedback from the teaching attending physician based upon
direct observation and focused upon the following six competencies:
1) Gathers essential and accurate information about the patient through interviews,
examination, and complete history and by appropriately accessing adjunctive
sources of information to this obtained from the patient and/or family members.
2) Makes informed diagnostic and therapeutic decisions based on patient
information, current scientific evidence, clinical judgment, and patient preference
3) Carries out patient management plans based on age, diagnosis and
psychosocial issues, including, but not limited to, management of patients with
ischemic heart disease, congestive heart failure, valvular heart disease, and
disorders of cardiac rhythm.
1) Understands and correctly inteprets M-mode, 2-D, and Doppler
Echocardiograms and integrates this knowledge in the care of patients on the VA
2) Understands current guidelines for the treatment of patients with unstable
coronary syndromes and acute myocardial infarction.
3) Understands treatment options for acute heart failure, including the use of
inotropes, vasodilators, assist devices, and cardiac transplantation.
4) Understands indications for treatment and treatment options for complex
5) Understands and appropriately applies current guidelines for peri-operative
cardiovascular evaluation prior to non-cardiac surgery.
Practice-Based Learning and Improvement:
1) Uses feedback to identify areas for improvement.
2) Seeks opportunities to strengthen deficits in knowledge/skills.
3) Demonstrates initiative in researching current scientific evidence and applying it
to problems encountered during daily practice.
Interpersonal and Communication Skills:
1) Communicate effectively with other members of a multi-disciplinary team,
working effectively with others as a leader of the health care team, member or
2) Maintains comprehensive, timely and legible medical record demonstration and
correspondence related to patient care activities.
3) Provides accurate and timely feedback to referring physician.
4) Actively listens and elicits appropriate information from the patient and/or family
members and colleagues.
1) Recognizes ethical dilemmas and utilizes / seeks out appropriate consultation
2) Obtains informed consent from patient and/or family member/legal guardian.
3) Adheres to the laws and rules governing the confidentiality of patient information.
4) Engages in ethical business practices and adheres to the institution’s Code of
Systems Based Practice:
1) Understands, accesses, utilizes and evaluates effectiveness of resource
providers, and systems to provide optimal cardiac therapy.
2) Understands different medical practice models and delivery systems and how to
best utilize them to care for the individual patient.
3) Practices quality, cost-effective health care.
4) Advocates and facilitates patient advancement through the health care system